NoYesRLNo Influenza Vaccination Consent Form
Resident Information Screening for influenza vaccine eligibility 1.Do you have a severe allergy to eggs? 2.Have you ever had a life-threatening reaction to the influenza vaccine? 4.Are you moderately or severely ill today? 3.Do you have a history of Guillain-Barre Syndrome? If yes to any questions 1-3 then DO NOT vaccinate with influenza vaccine. ................
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